Research letter
Trends in the Prescribing of Antidiabetic Drugs
An Analysis of Nationwide Drug Prescribing and Diagnostic Data from the German Statutory Health Insurance System
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The number of patients with type 2 diabetes (T2D) is steadily increasing worldwide. In 2023, 9.5% of the population living in Germany were affected (1). Obesity and lack of physical activity are key risk factors. Newer antidiabetic drugs, such as GLP-1 receptor agonists (GLP-1RAs) and SGLT-2 inhibitors (SGLT2i), support weight loss and have cardioprotective and renoprotective effects (2). However, GLP-1RAs and SGLT2i are considerably more expensive compared to older antidiabetic drugs such as metformin. In addition, the fact that semaglutide has been aggressively marketed as a weight loss drug since 2023 has resulted in high demand, with supply shortages for patients with type 2 diabetes being suspected. The actual prescription data needed to evaluate these potential shortages is still missing. The aim of this analysis is to reveal the development of the frequency of antidiabetic drug prescriptions from 2020 to 2024, both overall and among T2D patients newly started on medication. This insight should allow predictions to be made about cost developments and enable the assessment of potential effects of supply shortages and indication extensions.
Methods
Nationwide drug prescription and diagnostic data from the German Statutory Health Insurance system from the first quarter (Q1) of 2017 to Q1 2025/Q2 2024 (drug prescription data/diagnostic data) were compiled on a quarterly basis at the patient level with a focus on GLP-1RAs and other economically relevant groups of active substances in antidiabetic drugs.
Prescription and expenditure shares overall
The prescription percentage share of each substance group was calculated for all blood glucose-lowering drugs excluding insulins (ATC group A10B). As a dual GLP-1/GIP receptor agonist, tirzepatide was included in the GLP-1RA group.
New prescriptions
For the analysis of new prescriptions for T2D, all patients with confirmed diabetes diagnosis (ICD10-GM E11–E14) in at least two of four quarters, aged ≤ 109 years, and with valid gender information (male/female) were identified. Commencing with the first diagnostic quarter, prescriptions for an antidiabetic drug were defined as new prescriptions on a quarterly basis, if they were written after at least four quarters in which no antidiabetic drug had been prescribed. The new prescription rates were calculated as the proportion of patients with new prescriptions from the respective substance group in relation to the total number of new prescriptions from the A10B group. Patients newly prescribed insulin alone (ATC A10A) were not included in order to exclude type 1 diabetes patients. More than one count of patients was possible if different substances were prescribed in the same quarter, allowing a total of 3.46 million new prescriptions from 2.86 million persons with T2D to be analyzed.
Results
Development of the prescription and expenditure shares
Overall, prescriptions from the A10B group increased from 17.3 million in 2017 to 26.8 million in 2024 (+54.4%). While the share of metformin decreased from 50.1% to 37% (−13.1%) in the period 2020–Q1 2025, the shares of SGLT2i and GLP-1RAs (including tirzepatide) increased to 29.1% (+18.4%) and 12.9% (+6.6%), respectively (Figure). Despite the high proportion of prescriptions for metformin, it accounted for only 12.6% of the total A10B expenditure in 2017. This proportion decreased to 5.1% by Q1 2025. Between 2017 and 2024, the total cost of antidiabetic drugs of the A10B group increased from €1.12 billion to €3.07 billion (+174.9%). Initially, the proportion of expenditure on SGLT2i rose moderately to 29.2% in 2021. From 2022 onwards, however, expenditure grew disproportionately fast in relation to the number of prescriptions, climbing to 56.1% in 2024. Until the third quarter of 2021, GLP-1RAs were the group with the highest proportionate costs (29.7%), yet they were subsequently surpassed by SGLT2i.
New prescriptions
In 2017, the majority of new prescriptions for T2D were still for metformin (72.5%), DPP4 inhibitors (10.7%) and sulfonylureas (4%) (Table). The rates of new prescriptions for these substance groups have been decreasing steadily, at the latest since 2020. In 2023, the majority of patients (57.1%) continued to be prescribed metformin, but 25.4% of patients were prescribed SGLT2i (possibly in addition) and 4.9% were prescribed GLP-1RAs. These trends continued in 2024, with the exception of GLP-1RAs. While the rate of new GLP-1RA prescriptions declined, the rate of new prescriptions of tirzepatide (market launch in November 2023) rose sharply.
Discussion
Overall, expenditure on antidiabetic drugs more than doubled (+174.9%) between 2017 and 2024, while prescriptions increased by 54.4%. This mounting economic challenge is attributable to the observed decline in prescriptions for metformin and the increase in prescribing cost-intensive active substances such as SGLT2i and GLP-1RAs. While the cost of a daily maintenance dose of metformin is currently (3) €0.20, SGLT2i are 6 to 12 times more expensive (for example: ertugliflozin: €1.15, dapagliflozin: €2.42) and GLP-1(/GIP)RAs are 17 to 87 times more expensive (for example: semaglutide: €3.46; tirzepatide: €9.62–€17.47, depending on dosage and package size). This trend could be further intensified in the future by indication extensions, as observed with SGLT2i in 2022 (4).
The fact that after T2D diagnosis, SGLT2i and GLP-1RAs were increasingly prescribed in addition to metformin in the first half of the 2024 points to a shift from a focus on blood sugar control to a stronger focus on cardio- and renoprotective treatment goals. While this analysis does not allow for causal conclusions, the declining rate of new prescriptions for GLP-1RAs combined with a simultaneous increase in tirzepatide prescriptions suggests a connection with the supply shortages (Figure), in addition to a possible preference due to greater effectiveness. Shortages of this kind could affect treatment decisions and thus the quality and cost of care. According to a US study, the high costs of GLP-1RAs prevent cost-effective treatment despite the great benefits of GLP-1RAs in weight reduction and prevention of cardiovascular events (5). Discussions about extensions of indication and reimbursement by statutory health insurance providers should take these findings into account.
Lena M. Paschke, Kerstin Klimke, Maike Below
Zentralinstitut für die kassenärztliche Versorgung in Deutschland, Berlin, Germany (Paschke, Klimke, Below); lpaschke@zi.de
Conflict of interest
The authors declare no conflict of interest.
Manuscript received on 6 May 2025, revised version accepted on 19 August 2025
Translated from the original German by Ralf Thoene, M.D.
Cite this as:
Paschke LM, Klimke K, Below M: Trends in the prescribing of antidiabetic drugs: An analysis of nationwide drug prescribing and diagnostic data from the German statutory health insurance system. Dtsch Arztebl Int 2025; 122: 678–9. DOI: 10.3238/arztebl.m2025.0153
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